quality payment program · ― must include at least one outcome or high priority measure • earn...
TRANSCRIPT
Quality Payment Program
Mona Mathews, MA, PMP
Chris Becker, CPHIMS, CPHIT
Lori Manteufel, BBA
Health Care Quality Symposium
November 14, 2018
1
Disclaimer
Content provided in this presentation is based on the
latest information made available by the Centers for
Medicare & Medicaid Services (CMS) and is subject
to change.
CMS policies change, so we encourage you to
review specific statutes and regulations that may
apply to you for interpretation and updates.
2
Objectives
1.Understand the Quality Payment Program
(QPP)
2.Learn how others communicated the QPP to
physicians and staff
3.Understand changes in 2018 QPP
4.Learn how to estimate your Merit-based
Incentive Payment System (MIPS) score to
help you set improvement goals
5.Review the 2019 QPP proposed rule
3
Introductions
4
Lake Superior Quality Innovation Network
Lake Superior Quality Innovation Network
(Lake Superior QIN) is comprised of three quality
improvement organizations:
• Stratis Health in Minnesota
• MetaStar in Wisconsin
• MPRO in Michigan
5
MetaStar is a member of the Quality Payment Program Resource
Center® for the Midwest, a Centers for Medicare & Medicaid Services-
funded collaboration among 10 key partners across Michigan, Ohio,
Indiana, Illinois, Kentucky, Wisconsin and Minnesota, focused on
supporting providers in small practices, and rural or underserved areas.
Our Resource Center® provides free help to eligible clinicians as they
navigate participation in the Quality Payment Program.
6
2017 Reporting and Performance Feedback
7
2017 Reporting Observations
Most practices experienced a smooth reporting process
Challenges
• Obtaining Enterprise Identity Management
(EIDM) service account
• No submit button
• Uploading quality data
8
Lessons Learned from 2017 Reporting
• Obtain an EIDM account early and make sure you
can log in
• Work with your vendor to make sure you have the
proper files to upload to the reporting portal
• There is no submit button
• You can report multiple times for groups and
individuals
9
Performance Feedback
Immediate feedback was given during the reporting
period
• This feedback changed during the reporting
period
• Feedback was only an estimate
• Did not reflect any special scoring, hardship
application status or Improvement Study
Participation and Results
Official feedback results became available on
July 1, 2018
10
Which Clinicians will have MIPS Performance Feedback
• Individual clinicians (including voluntary submitters),
groups, and MIPS Alternative Payment Model
(APM) Entities
• Clinicians who practice in multiple groups, as
identified by a Taxpayer Identification Number
(TIN), will have performance feedback for each
group under which they participated in MIPS
• Partial Qualifying APM Participants (Partial QPs)
will only receive MIPS performance Feedback if
they elected to participate in MIPS
11
Group Discussion
12
Questions
What was your experience with 2017 reporting?
• Reporting portal
• Problems with reporting
• Resources you utilized
How did you share feedback reports with clinicians and staff?
What factors influenced you when it came to sharing
feedback information?
Did any of you file a targeted review and if you did what was
your experience with the process? If yes, what was the
result?
13
2018 Program Overview
14
MIPS Eligible Clinicians (EC)
*Physicians: Doctors of medicine, osteopathy, dental surgery, dental
medicine, podiatric medicine, or optometry, and chiropractors*
*With respect to certain specified treatment, a Doctor of Chiropractic legally authorized to practice
by a state in which he/she performs this function
Physicians* Nurse
Practitioners
Physician
Assistants
Clinical
Nurse
Specialists
Certified
Registered
Nurse
Anesthetists
No change in the TYPES of clinicians eligible to participate in 2018
15
2018 Year 2 MIPS Eligible Clinicians
2017 Year 1
• Bill > $30,000 Medicare Part B AND
• Provide care to > 100 beneficiaries
2018 Year 2
• Bill > $90,000 to Medicare Part B AND
• Provide care to > 200 beneficiaries
Low-volume threshold for 2018 Year 2 changes to INCLUDE MIPS eligible
clinicians billing more than $90,000 a year in Medicare Part B allowed charges
AND providing care for more than 200 Medicare patients a year.
*Voluntary reporting remains an option for clinicians exempt from MIPS
16
No Change in Basic MIPS Exemption Criteria
1. First year enrolled in Medicare
2. Significantly Participating in an Advanced APM
• 25 percent of Medicare payments paid through Advanced APM
• 20 percent of Medicare beneficiaries seen through Advanced APM
3. Low Volume Threshold
• Exempt if either < $90,000 billed OR < 200 visits during
determination period (in either of two prior billing years)
• Determined at TIN/National Provider Identifier (NPI)) for
individuals, AND
• At the group TIN for groups
17
QPP Eligibility Look Up Results
MIPS
Participation
Status Tool
Source: https://qpp.cms.gov/participation-lookup
18
2018 Reporting Options
Clinicians participating as a group are assessed as a
group across all four MIPS performance categories.
The same is true for clinicians participating as a
Virtual Group.
Source: CMS-QPP-Year-2-Final-Rule-National Provider Call-Slides.2017.11.30
19
Two Paths for QPP: MIPS and APMs
Path One: APMs
Advanced APMs and MIPS APMs
20
Path One: Advanced APMs
Alternative Payment ModelsNew models of paying for health care that incentivize quality and value over
volume by moving away from traditional Medicare Part B Physician Fee Service.
Advanced APMs
Subset of APMs that receive a 5 percent bonus payments if ECs meet
thresholds to become Qualified Professionals
Three statutory requirements:1. Participants must use certified electronic health record (EHR) technology
2. Payment for covered services based on quality measures comparable to MIPS
3. Entity is either 1)
―a Medical Home Model expanded under CMS Innovation Center authority OR
―Requires participants to bear more than a nominal amount of financial risk
21
APM
Advanced
APMs
APM
MIPS APM
MIPS
What are MIPS APMs?
Middle ground between reporting to MIPS categories and being a full-fledged
Advanced APM
Examples:
• ECs in Advanced APMs who don’t meet thresholds for Advanced APM
• Medicare Shared Savings Program (MSSP) Track 1 (Upside risk, no downside risk)
MIPS Eligible CliniciansQualified
Participants
MIPS Eligible
Clinicians
Source: https://qpp.cms.gov/
22
Two Paths for QPP:
Path Two: MIPS
23
Path Two: MIPS
Previous
Category –
Year
Physician Quality
Reporting System
(PQRS)
New CategoryEHR Incentive
Program
Value Based
Modifier (VBM)
2018 50 % 15 % 25 % 10 %
2017 60 % 15% 25% 0 %Source: CMS Quality Payment Program – Train-the-Trainer
Quality Improvement
ActivitiesPromoting
Interoperability Cost
Four MIPS category scores compiled for
MIPS final score worth up to 100 points
24
MIPS: Quality Category
25
Quality Category: 50 percent of MIPS Score in 2018
Earn up to 60 Quality Category points
• Scored on the highest six quality measures from 277 measures
― May pick from specialty set
― Must include at least one outcome or high priority measure
• Earn three to 10 category points for measures with benchmarks
• Earn up to seven points for six measures - if “topped out*” two or more years*
― Must meet data completeness criteria (2018 increased to 60 percent)
• 2018 Earn one point for reporting if data completeness not met
― Small practices still earn three points
• Bonus points for reporting end to end electronically (electronic clinical quality
measure (eCQM))
• Bonus points for reporting additional outcome or high priority measures
*Topped out measures have little room for improvement
26
Quality Category: 50 percent of MIPS Score in 2018
New: Scoring Improvement Bonus
worth up to 10 percentage points • Based on improvements in total category score
• Higher improvement results in more points
MIPS Reporting methods
1. Claims, EHR, Registry, Qualified Clinical Data Registry (QCDR) -60 category points
• Each reporting method has different benchmarks
2. CMS Web Interface 110 - 140 category points
• Only for groups of 25 plus
• Must report on 14 quality measures
• APMs report collectively as an entity (all TINs)
27
2018 Specialty Measure Sets
1. Allergy/Immunology2. Anesthesiology 3. Cardiology 4. Dentistry5. Dermatology 6. Diagnostic Radiology7. EPT Cardiology 8. Emergency Medicine9. Gastroenterology 10.General Oncology 11.General/Family Practice 12.General surgery 13.Hospitalist 14. Infectious Disease 15. Internal Medicine 16. Interventional Radiology 17.Mental/Behavioral Health18.Nephrology
19.Neurology20.Neurosurgical21.Obstetrics/Gynecology22.Ophthalmology23.Orthopedic Surgery24.Otolaryngology25.Pathology26.Pediatrics27.Physical Medicine28.Plastic Surgery29.Podiatry 30.Preventive Medicine 31.Radiation Oncology32.Rheumatology 33.Thoracic Surgery34.Urology 35.Vascular Surgery
28
MIPS Quality Measures
https://qpp.cms.gov/mips/quality-measures
29
MIPS Quality Benchmarks
To score more than three points:1. Benchmark
2. Minimum case size of 20
3. Data completeness
• Claims: >50 percent of Part B claims
• QCDR, Registry, EHR: > 50 percent
of all payers
• CMS WI: First 243 claims
Measur
e ID
Measure_N
ame
Reportin
g
Method
Measur
e Type
Benc
h
mark
High
Priority
Topped
Out Decile_3 Decile_4 Decile_5 Decile_6 Decile_7 Decile_8 Decile_9
Decile_
10
112
Breast
Cancer
Screening Claims Process Y N Yes
38.46 -
48.01
48.02 -
55.67
55.68 -
62.78
62.79 -
69.41
69.42 -
77.18
77.19 -
87.87
87.88 -
98.52
>=
98.53
112
Breast
Cancer
Screening EHR Process Y N Yes
12.41 -
22.21
22.22 -
32.30
32.31 -
40.86
40.87 -
47.91
47.92 -
55.25
55.26 -
63.06
63.07 -
73.22
>=
73.23
112
Breast
Cancer
Screening Registry Process Y N Yes
14.49 -
24.52
24.53 -
35.70
35.71 -
46.01
46.02 -
55.06
55.07 -
63.67
63.68 -
74.06
74.07 -
87.92
>=
87.93
ACO-20
Breast
Cancer
Screening
CMS
Web
Interface Process Y N Yes 30 40 50 60 70 80 90 100
30
MIPS: Cost category
31
Cost: 10 percent of MIPS Score in 2018
Category Performance Score included in composite MIPS score starting in 2018
TWO measure scores are averaged (or any one available)
1.Medicare Spending per Beneficiary (MSPB)
2.Total per capita cost measures
• Category score weight will increase to 30 percent by 2021
• No data submission required; Calculated from administrative claims if meet case minimum of attributed patients
• Benchmark calculated using current year performance
• New: Scoring Improvement Bonus up to one percentage point
― Based on statistically significant changes at the measure level
32
MIPS: Improvement Activities (IA) Category
33
Improvement Activities: 15 percent of MIPS Score 2017-2018
Maximum Category score 40 points
• Help participants prepare to transition to APMs and Medical Home Models. Additional activities available in 2018, some changed
• Engage in up to four activities for at least 90 days
― Medium activity = 10 points
― High activity = 20 points
• Earn Promoting Interoperability (PI) category Bonus points for using CEHRT for some IA
• Report by simple Yes/No attestation
Special Scoring:• Full credit (40 points): clinicians in patient-centered medical home (PCMH),
MSSP, Next Generation APM
• Half credit (20 points): clinicians in other APMs
• Double points: clinicians in small underserved or rural settings, and non-patient facing clinicians/groups
34
MIPS Improvement Activities
*Many others available
35
Path Two: MIPS
Promoting Interoperability(PI) category
36
Promoting Interoperability: 25 percent of MIPS Score in 2018
Maximum Category score 100 of 155 possible points
Earn up to 25 MIPS points
2018: May use either 2014 or 2015 Certified EHR Technology (CEHRT) (or combination)
• 10 percent bonus for using only 2015 CERHT
• Base measures, required for any score in this category
― Earn 50 points
― Four base measures for 2014 CEHRT, five for 2015 CEHRT; some measures also earn performance scores
― Exclusions available for two base measures: e-Prescribing and Health Information Exchange: Send Summary of Care
• Performance measures Optional
― Earn up to 90 points
― Seven for 2014 CEHRT, nine for 2015 CEHRT
37
Promoting Interoperability: 25 percent of MIPS Score
Bonus points
Earn up to 25 percent in 2018 ― Use 2015 Certified EHR Technology exclusively – 10 percent
― Use CEHRT for at least one Improvement Activity (IA) – 10 percent
― Report to one public health (PH) or clinical registry - 10 percent
― Report to any additional PH or clinical registry – 5 percent
38
Automatic Reweighting of Promoting Interoperability
PI category is automatically reweighted to quality when: (unless EC reports data to IA category)
1. MIPS EC types: nurse practitioner (NP), clinical nurse specialists (CNS),
certified registered nurse anesthetist (CRNA), physician assistant (PA)
2. Some “Special Status” MIPS ECs:
• Non-patient facing: ≤100 Medicare B patient-encounters
• Hospital-based: >75 percent encounters in hospital setting
― inpatient, on-campus outpatient hospital or emergency department
(ED); Point of Service (POS) 21-23
3. Groups with > 75 percent of clinicians meeting Special Status
39
Application for Reweighting of Promoting Interoperability
PI is NOT automatically reweighted to quality for these types of MIPS ECs
• EC must apply for hardship exception
1. Clinicians in small practices
2. EHR decertified - retroactive to 2017
3. Significant hardship exception
― Five year limit removed
4. CMS designated natural disasters (Federal Emergency Management Agency (FEMA))
Applications for reweighting must be submitted by December 31, 2018
40
2014 vs 2015 Certified EHR
Four Base Measures = 50 points
Seven Performance Measures
• Earn up to 10 points each
• Two worth 20 points each
Five Base Measures = 50 points
Nine Performance Measures
• Earn up to 10 points each
2
0
1
4
C
E
H
R
T
MEASURE NAME
Security Risk Analysis (Base)
e-Prescribing (Base)
Send Summary of Care (Base)
Provide Patient Access (Base)
Immunization Registry Reporting
Medication Reconciliation
Patient-Specific Education
Secure Messaging
View, Download, or Transmit (VDT)
Specialized Registry Reporting
Syndromic Surveillance Reporting
2
0
1
5
C
E
H
R
T
MEASURE NAME
Security Risk Analysis (Base)
e-Prescribing (Base)
Send Summary of Care (Base)
Request/Accept Summary of Care (Base)
Provide Patient Access (Base)
Clinical Information Reconciliation
Patient-generated Health Data
Immunization Registry Reporting
Patient-Specific Education
Secure Messaging
View, Download, or Transmit (VDT)
Clinical Data Registry Reporting
Public Health Registry Reporting
Electronic Case Reporting
Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses,
but maximum category score is 100
41
MIPS Scoring and Reporting
42
Performance Period 2017 - 2018
Promoting
Interoperability Promoting
Interoperability
Source: CMS Quality Payment Program – Train-The-Trainer
43
Virtual Groups
• Solo practitioners and groups of 10 or less EC come
together virtually to participate in MIPS as a group
• Election process must occur before beginning of
performance period
―Election period October 11 - December 31, 2017
for 2018 performance period
• No changes after performance period starts
44
MIPS 2018 Year 2Scoring (0-100 Points)
≥70 points Eligible for positive payment adjustment and exceptional
performance bonus payment
15.99 – 69.99 points Positive payment adjustment. No exceptional performance
bonus payment. No negative payment adjustment
15 points Neutral payment adjustment
3.76 – 14.99 points Negative payment adjustment ranges from -4.9 percent to - 0.1
percent
0 - 3.75 points -5 percent payment adjustment.
Increase in performance threshold and payment adjustment
Source: Stratis Health MIPS Estimator, https://www.mipsestimator.org
45
New Bonuses in 2018
Bonus eligibility: Must report on at least one MIPS category
Bonus added to final MIPS Score
1. Complex Patient Bonus
Up to five bonus points for treating complex patients. Score based on
• Hierarchical Condition Category (HCC) risk score +
• Percentage of dual eligible beneficiaries
2. Small Practice Bonus
Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)
46
Scoring Examples
47
Scenario One
Background• Solo Practice Surgeon
• Eligible Clinician (exceeds low volume threshold)
• Must report to avoid a negative penalty
• Does not utilize an EHR
Reporting Options• Needs to obtain 15 MIPS Points to remain Neutral
• Could attest to Improvement Activities
• Report Quality Category via claims or registry
• Note: Practices with 15 or less clinicians get some special scoring
48
Solo Surgeon Reporting with No EHR
• Clinician decides that she does not want to pay for a
registry and go through the trouble of doing chart
reviews to populate the registry
• Finds out that billers have been submitting some “G”
Codes for Medication Reconciliation and Body Mass
Index Screening but they did not meet the 60 percent
data completeness for quality
• Attests to using the Prescription Drug Monitoring
Program (PDMP)
49
Score for this Solo Clinician
One
Improvement
Activity
Two Quality
Measures
Five free
points for
being a small
practice
Small Practices receive double points for Improvement Activities and a
minimum of three points for quality measures Source: Stratis Health MIPS Estimator
https://www.mipsestimator.org/
50
Scenario Two
Background
• Group Practice with 16 Eligible Clinician Types
• Has EHR through the local hospital
• Two of the clinicians exceed the low Volume Threshold
• The remaining 14 are eligible at the group level but not
individually
Reporting Options
• Group Reporting
• Individual Reports (two mandatory and 14 voluntary)
51
Scores for Mandatory Clinicians
Patricia WhiteWilliam White
Source: Stratis Health MIPS Estimator https://www.mipsestimator.org/
52
Group Score
Source: Stratis Health MIPS Estimator https://www.mipsestimator.org/
53
Group versus Individual Reports
Individual Report – The individual clinicians will
receive a payment adjustment
Group report – All eligible clinician types in the group
will receive a payment adjustment
In this example, the group score was greater than
either of the mandatory reporters so if a group report
was submitted, they would receive the higher of the
two scores.
54
Important Information About the Scenarios
Did not give any points for cost or complex patient
bonus
The scores were calculated based on the most
current benchmarks (some benchmarks will be
recalculated during the performance year)
55
Steps to Success in the Quality Payment Program
56
Steps to Success in the QPP
Determine Eligible Clinicians
Determine path:
• APM (group) or
• MIPS (individual or group)
Collect data:
• Promoting Interoperability
• Quality measures
• Improvement activities
57
EIDM Account Set Up
To login and submit data, clinicians will use their Enterprise Identity Management (EIDM) credentials.
• The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems.
• The system will connect each user with their practice Taxpayer Identification Number (TIN). Once connected, clinicians will be able to report data for the practice as a group, or for individual clinicians within the practice.
• To learn about how to create an EIDM account, see this user guide.
• Quick Start Guide
58
Clinicians: Steps to Success in the QPP - continued
Review current performance
• Foster performance improvement
• Choose reporting periods for PI and IA
― 90 - 365 days
― Full calendar year for quality reporting
• Evaluate available reporting methods
• Choose group or individual performance
59
2019 Quality Payment Rule
60
2019 Rule Overview
• Rule was released on November 1, 2018 via the
Medicare Physician Fee Schedule (PFS)
• MIPS is continuing to ramp up
• New eligible clinician types
• Potential incentives and penalties increase
61
What is Not Changing
Timeline
• Performance period: January – December 2019
• Reporting period – March 2020
• Payment adjustment, begins January 1, 2021
Performance Period
• Quality and Cost: 12 months
• Improvement Activities and Promoting Interoperability 90 days
Types of exemptions
• Newly enrolled in Medicare
• Below low-volume threshold
• Significantly participating in Advanced APMs
62
MIPS Performance Period 2019
Source: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-MIPS-quick-start-guide.pdf
63
Key Changes
• Category weights change slightly – increase in cost and
decrease in quality
• Newly eligible clinician types
• Increase in performance thresholds, incentives and penalties
• Limiting the use of claims-based measures
• CEHRT Requirements – must use 2015 certification
• Third criterion for determining the MIPS Eligibility
• Opt in option for clinicians that meet at least one low volume
criteria
64
Category Weighting for 2019
Quality – 45 percent
• Data Completeness remains at 60 percent
• Claims Submission only for small practices
(15 or fewer clinicians)
Cost – 15 percent
Improvement Activities – 15 percent
Promoting Interoperability – 25 percent
• Must use 2016 CHERT
65
Eligible Clinician Types
Physical and
Occupational
Therapists
Qualified
Speech-
Language
Pathologists
Qualified
Audiologists
Clinical
Psychologists
Registered
Dieticians and
Nutrition
Professionals
Physicians Nurse
Practitioners
Physician
Assistants
Clinical
Nurse
Specialists
Certified
Registered
Nurse
Anesthetists
Year 1 and 2 Eligible Clinicians
2019 Newly Eligible Clinicians
66
Performance Threshold and Payment Adjustment
• Must obtain a minimum of 30 MIPS points to remain
neutral
• Exceptional bonus requires 75 MIPS points
• Maximum negative payment adjustment is 7 percent
• Performance in 2019 will affect Medicare payments
in 2021
67
Low-Volume Threshold Criteria
Source: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-MIPS-quick-start-guide.pdf
68
Small Practices
• Definition – 15 or fewer clinicians under the same TIN
• Increase the small practice bonus to six points, but include it
in the Quality performance category score
― Must report quality measures
― Bonus points subject to category weighting
• Continue to award small practices three points for submitting
quality measures that do not meet the data completeness
requirements
• Can continue to submit quality measures through Medicare
Part B Claims
• Option to participate as a virtual group
69
Audits: Are you Ready?
70
Historical Perspective
• Audits do happen
• Meaningful Use (MU) participants had an approximate one in
10 chance of being audited
• Auditors did retract incentive funds on behalf of CMS when
program participants failed the audit.
• Number one audit flag and reason for payment retraction:
― poorly done or no Security Risk Assessment for the
Protect Patient Health Information objective
• Biggest risk: not being prepared for an audit
• Prior MU program required two week response time to audit
materials request
71
Historical Perspective
• Six year retention period required for MU
attestation documentation
• Audits under MU were performed by a
contracted company (Figliozzi & Co.)
• Following two slides are excerpts from CMS
guidance document on MU audit program
72
Historical Perspective
73
Historical Perspective
74
The Basics of Audit Readiness
• Audits are in the news and have our attention
• June 12, 2017 article in ‘Fierce Healthcare’ online:
”Audit estimates CMS issued hundreds of millions
of dollars worth of incorrect EHR incentives”
• Detailed Office of Inspector General (OIG) PDF at:https://oig.hhs.gov/oas/reports/region5/51400047.pdf
75
Main Points in OIG Report
“On the basis of our sample results, we estimated that
CMS inappropriately paid $729,424,395 in incentive
payments to EPs who did not meet meaningful use
requirements. These errors occurred because sampled
EPs [Eligible Providers] did not maintain support
for their attestations. Furthermore, CMS conducted
minimal documentation reviews of self-attestations,
leaving the EHR program vulnerable to abuse and
misuse of Federal funds”
76
OIG recommends that CMS…
• Review eligible professionals (EP) incentive payments to determine which
EPs did not meet meaningful use measures for each applicable program
year to attempt recovery of the $729,424,395 in estimated inappropriate
incentive payments,
• Review a random sample of EPs’ documentation supporting their self-
attestations to identify inappropriate incentive payments that may have been
made after the audit period,
• Educate EPs on proper documentation requirements,
• Finally, as CMS implements MACRA, we recommend that any modifications
to the EHR meaningful use requirements include stronger program
integrity safeguards that allow for more consistent verification of the
reporting of required measures so that CMS can ensure that EPs are using
EHR technology consistent with CMS’s goal of Advancing Care Information
under MIPS.
77
The Basics of Audit Readiness
• Additional call by two senators on July 12 for follow
up on improper $730M payments
(Letter to CMS Administrator from Senators Hatch
and Grassley)
“If CMS is capable of recovering taxpayer money
that should have not have been spent, the agency
should take all reasonable steps to do so,” the
Senators wrote.
Source: Healthcare IT News: http://tinyurl.com/y8st79c2
78
Senators Foreshadow MIPS Auditing
79
Which Categories MIPS May Be Audited
CMS has
supplied
‘Data
Validation’
Excel tool
for IA
No CMS
guidance as
of yet.
Relying on
previous MU
information
No CMS
guidance as
of yet.
Relying on
PQRS and
MU previous
information
80
CMS Data Validation & Audit Fact Sheet
• CMS has provided a Data Validation and Audit Fact
Sheethttps://qpp.cms.gov/docs/QPP_MIPS_Data_Validation_Criteria.zip
• CMS requires a six year retention period for MIPS and
Federal False Claims Act encourages up to 10 years
81
CMS Data Validation and Audit Fact Sheet
• The Data Validation and Audit Fact Sheet is only three
pages and does not provide detailed guidance
• At the bottom of page 1, CMS states:
“Under MIPS, CMS will conduct an annual data
validation process. Additionally, you could receive a
request from CMS for an audit, which requires an
initial response within 10 business days.”
• CMS will ‘validate’ the data your submit and may
also conduct an audit. Two separate and distinct
activities
82
Audit Readiness Excel Tool
83
Audit Readiness Excel Tool
84
Your Audit Readiness Files
• Best approach is an electronic set of files/folder for
quick response to CMS
• Prior submissions to the CMS contracted auditor
were done primarily via secure web portal (uploads)
• Organize at the TIN level as that is how the program
is organized and audit info will be requested
• Base your electronic folder structure on how you are
attesting (by individual provider or by a group) and
break down further into MIPS reporting categories.
• Create a year by year file structure
85
Questions?
Mona Mathews, Project Specialist
Chris Becker, Project Specialist
Lori Manteufel, Project Specialist
www.lsqin.org
www.metastar.com
This material was prepared by the Lake Superior
Quality Innovation Network, under contract with
the Centers for Medicare & Medicaid Services
(CMS), an agency of the U.S. Department of
Health and Human Services. The materials do
not necessarily reflect CMS policy.
11SOW-WI-A1-18-47 110718